ODs' Quest to Perform Surgery

LIn terms of optometrists' “quest” to perform invasive eye surgery, I believe there are some practitioners who would like to be able to do everything under the sun, probably including brain surgery. The real aims are to make eye care as convenient as possible for patients and for optometrists to provide legitimate, safe eye health care with minimal inconvenience, expense, and travel time for patients.

A classic example is the shift in optometric practice in Oklahoma—an almost 20-year-old issue—such that optometrists may perform extremely safe ophthalmic laser procedures, such as YAG capsulotomy and argon laser trabeculoplasty. The motivating factors behind this shift in surgical privileges included (1) the rural distribution of patients in need of eye health care, (2) the urban location of the ophthalmologists, (3) the multiple-day delays between identifying a patient's need for a procedure and performing that procedure, and (4) the inability or overwhelming reluctance of a number of those patients to make the trek to Tulsa, Oklahoma City, or other faraway metropolitan cities that are heavily populated with ophthalmologists. The question that optometrists want to answer is how do we provide surgical care to patients elsewhere than Oklahoma who need it, want it, but either cannot or will not travel long distances for it?

INVASIVE SURGERY
Typically, optometrists only seek to do what I would describe as minor surgical procedures including the anterior segment laser procedures noted earlier, lid lesion removals and biopsies, punctal cautery, etc., not major, high-risk, extensively invasive procedures including retinal buckles, submacular net removals, optic nerve decompressions, etc. Any procedure that involves cutting the eye is invasive but not necessarily high-risk. Physicians in any subspecialty, not just optometry or ophthalmology, could argue that lancing a boil or popping a blister constitutes surgery by definition. At issue for optometrists are procedures such as chalazion removal, cutaneous horn removal, and wart removal around the eye, for all of which there is a huge margin of safety.

EDUCATION AND TRAINING
The public health need will dictate where additional health providers are necessary. Subsequently, it will become the responsibility of the respective schools and colleges to ensure that academia delivers the training that meets or exceeds anything necessary to achieve the competence and practitioner confidence to do the procedure.

In the late 1980s, optometry tried to model its training around ophthalmology. The assignment was to develop a training program for aspiring optometrists that met or exceeded the equivalent training that an ophthalmologist received relative to a specific procedure. As in medicine, building on a solid fundamental core education, the optometrist would receive additional highly specific training in the mastery of a technique. For example, in the 1980s, an ophthalmologist who had completed medical school, residency training, and fellowship years before the YAG laser was developed could receive a “post-on-your-wall” credential signifying CME course completion following a 90-minute workshop at a major conference such as the AAO's annual meeting. Optometry has never credentialed an optometrist to use the YAG laser based upon 90 minutes of training because of state boards' insistence that optometric training exceed minimal standards acceptable elsewhere.

Ophthalmologists often use the aforementioned credentialing for privileging purposes. The credential states that an ophthalmologist has received appropriate training in a specific procedure and therefore should be considered competent to perform that procedure. Technically, however, it is not necessary for an MD or a DO to have that advanced training because of the unrestricted nature of the medical license. Optometry is a legislated profession with a scope of practice tightly defined in state laws and optometry board rules. Medicine is not similarly hampered by specific “cans” and “cannots” in its practice acts. Although common sense and fear of malpractice litigation dictate that both MDs and DOs stick within the comfort zone of their practice, training, and experience, technically, they do not have to.

Money Matters and Patient Demand
To totally deny an economic motivator behind optometrists' pursuit to perform surgery would be a mistake. As in all professions, economics play a part in which procedures optometrists want to offer as part of their practice. However, the principal motivation behind the majority of optometrists' desire to perform minor surgical procedures has been patient demand. Patients trust their doctor's of optometry to do necessary surgical or nonsurgical procedures correctly.

I am completely unaware of any optometrist's ever having misrepresenting herself or himself as a doctor of medicine or doctor of osteopathy. The optometrist tells the patient that she/he is an optometrist and has received training in the procedure that the patient is requesting. Routinely, optometrists acknowledge not having gone to medical school.

Refractive Surgery Comanagement
Optometrists perform the majority of eye care in this country. They detect refractive errors in patients that are amenable to laser treatment on a much more frequent basis than do ophthalmologists. If ophthalmologists want to perform more refractive procedures and they persuade optometrists to refer patients, then the ophthalmologists are successful. Refractive surgery comanagement was a concept hatched by ophthalmologists who wanted to increase optometric referrals.

MEDICAL SCHOOL/EDUCATION
I agree that patients' welfare is most protected when those performing surgery are able to recognize and manage complications and understand complex disease conditions. In all of the courses that I have either participated in or consulted on, the indications and contraindications for a procedure, the identification of complications, and their management were part of optometric training, education, and supplemental instruction. The contemporary core curriculum in optometry prepares graduates to recognize and deal with the complications associated with the procedures that optometrists have pursued. Additionally, there are a reiteration and a review of specifics in course work that go along with our workshops.

EXPANSIONS OF ODs' SCOPE OF PRACTICE
Optometrists' Therapeutic Pharmaceutical Agent rights provide optometrists critical access to the tools necessary to manage complications, at least the majority of them, in the event that there is postoperative pain or infection. It is appropriate for optometrists to have formulary drug access and prescribing rights, which enable them to deal with complications quickly and efficiently.

In the states where optometrists perform minor surgical procedures or administer periocular injections, these practitioners also have the legal authority to prescribe the types of medications that are necessary to manage an adverse outcome.

ODs TO PERFORM LASER SURGERY IN the department of veterans affairs
It sets an unfortunate and unnecessary precedent to force an optometrist who has been licensed and credentialed to perform laser procedures to act under the supervision of an ophthalmologist, simply because the ophthalmologist has a different set of letters following his name. If the state optometry board has approved the adequacy and the competence of the optometrist to perform the procedure, that is sufficient, in my opinion. The training an optometrist receives is more than adequate and safeguards the well-being of the patient.

In my opinion, ophthalmologists would have liked much more dramatic restrictions of optometrists' ability to perform any type of surgical procedure in the Department of Veteran Affairs setting. Ophthalmology's political goal was for anything remotely surgical to be declared out of the realm of optometric practice within the Department of Veteran Affairs system. At the same time, optometry would have preferred that there be no oversight or restrictive mandates on an appropriately credentialed optometrist to do the procedure. Neither ophthalmology nor optometry came out ahead.

MALPRACTICE
With some optometrists being permitted to perform minor surgical procedures including laser surgery, potential increases in malpractice insurance rates have become a common topic of optometrists' legislative discussions. To my knowledge, these rates have not risen because there have not been substantial or significant numbers of adverse outcomes. Is what happened to ophthalmologists' malpractice premiums likely to happen to optometrists? Perhaps, but the majority of lawsuits brought against ophthalmologists involve far riskier surgeries than what optometrists are seeking to perform. Few lawsuits are brought against an ophthalmologist for an unsuccessful chalazion removal, and I am unaware of any litigation brought against an optometrist for chalazion surgery gone sour.

LOCATION
In general, newly graduated health care providers, including vision care providers, tend to congregate in urban settings. They like the lifestyle that bigger cities afford. Here in Portland, Oregon, the number of ophthalmologists and optometrists greatly exceeds residents' needs in terms of vision care. By contrast, a lot of rural Americans are dramatically underserved. I think that this distribution problem needs to be addressed by both ophthalmology and optometry. Additionally, there is a documental disparity in the type of care that underrepresented minorities receive. Optometrists and ophthalmologists ought to be working together to try to bring optimal vision care to the people who currently lack it, not fighting over the right to perform minor surgery.

Leland Carr, OD, is Dean of Pacific University, College of Optometry in Portland, Oregon, and is the immediate past president of the Association of Schools and Colleges of Optometry. He may be reached at (503) 352-2202; carrl1@pacificu.edu.